Attachment 13 2021 BRFSS Field test questionniare

Public reporting burden of this collection of information is estimated to average 27 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-1061).

Form Approved

OMB No. 0920-1061

Exp. Date 3/31/2021

Interviewers do not need to read any part of the burden estimate nor provide the OMB number unless asked by the respondent for specific information. If a respondent asks for the length of time of the interview provide the most accurate information based on the version of the questionnaire that will be administered to that respondent. If the interviewer is not sure, provide the average time as indicated in the burden statement. If data collectors have questions concerning the BRFSS OMB process, please contact Carol Pierannunzi at [email protected].

HELLO, I am calling for the [STATE OF xxx] Department of Health. My name is (name). We are gathering information about the health of US residents. This project is conducted by the health department with assistance from the Centers for Disease Control and Prevention. Your telephone number has been chosen randomly, and I would like to ask some questions about health and health practices.

States may opt not to mention the state name to avoid refusals by out of state residents in the cell phone sample.

If cell phone respondent objects to being contacted by state where they have never lived, say:

“This survey is conducted by all states and your information will be forwarded to the correct state of residence”

Cell Phone Introduction

Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

CP01.

Is this a safe time to talk with you?

SAFETIME

1 Yes

Go to CP02

2 No

([set appointment if possible]) TERMINATE]

Thank you very much. We will call you back at a more convenient time.

CP02.

Is this [PHONE NUMBER]?

CTELNUM1

1 Yes

Go to CP03

2 No

TERMINATE

CP03.

Is this a cell phone?

CELLFON5

1 Yes

Go to CADULT1

2 No

TERMINATE

If "no”: thank you very much, but we are only interviewing persons on cell telephones at this time

CP04.

Are you 18 years of age or older?

CADULT1

1 Yes

2 No

TERMINATE

Read: Thank you very much but we are only interviewing persons aged 18 or older at this time.

CP05.

Are you male or female?

CELLSEX

1 Male

2 Female

We ask this question to determine which health related questions apply to each respondent. For example, persons who report males as their sex at birth might be asked about prostate health issues.

3 Nonbinary

7 Don’t know/Not sure

9 Refused

MSAB.01

What was your sex at birth? Was it male or female?

BIRTHSEX

1 Male

2 Female

This question refers to the original birth certificate of the respondent. It does not refer to amended birth certificates.

7 Don’t know/Not sure

9 Refused

TERMINATE

CP06.

Do you live in a private residence?

PVTRESD3

1 Yes

Go to CP08

Read if necessary: By private residence we mean someplace like a house or apartment

Do not read: Private residence includes any home where the respondent spends at least 30 days including vacation homes, RVs or other locations in which the respondent lives for portions of the year.

2 No

Go to CP07

CP07.

Do you live in college housing?

CCLGHOUS

1 Yes

Go to CP08

Read if necessary: By college housing we mean dormitory, graduate student or visiting faculty housing, or other housing arrangement provided by a college or university.

2 No

TERMINATE

Read: Thank you very much, but we are only interviewing persons who live in private residences or college housing at this time.

CP08.

Do you currently live in___(state)____?

CSTATE1

1 Yes

Go to CP10

2 No

Go to CP09

CP09.

In what state do you currently live?

RSPSTAT1

1 Alabama

2 Alaska

4 Arizona

5 Arkansas

6 California

8 Colorado

9 Connecticut

10 Delaware

11 District of Columbia

12 Florida

13 Georgia

15 Hawaii

16 Idaho

17 Illinois

18 Indiana

19 Iowa

20 Kansas

21 Kentucky

22 Louisiana

23 Maine

24 Maryland

25 Massachusetts

26 Michigan

27 Minnesota

28 Mississippi

29 Missouri

30 Montana

31 Nebraska

32 Nevada

33 New Hampshire

34 New Jersey

35 New Mexico

36 New York

37 North Carolina

38 North Dakota

39 Ohio

40 Oklahoma

41 Oregon

42 Pennsylvania

44 Rhode Island

45 South Carolina

46 South Dakota

47 Tennessee

48 Texas

49 Utah

50 Vermont

51 Virginia

53 Washington

54 West Virginia

55 Wisconsin

56 Wyoming

66 Guam

72 Puerto Rico

78 Virgin Islands

77 Live outside US and participating territories

99 Refused

TERMINATE

Read: Thank you very much, but we are only interviewing persons who live in the US.

CP11.

How many members of your household, including yourself, are 18 years of age or older?

HHADULT

_ _ Number

77 Don’t know/ Not sure

99 Refused

If CP07 = yes then number of adults is automatically set to 1

Transition to section 1.

I will not ask for your last name, address, or other personal information that can identify you. You do not have to answer any question you do not want to, and you can end the interview at any time. Any information you give me will not be connected to any personal information. If you have any questions about the survey, please call (give appropriate state telephone number).

Core Section 1: Health Status

Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

CHS.01

Would you say that in general your health is—

GENHLTH

Read:

1 Excellent

2 Very Good

3 Good

4 Fair

5 Poor

Do not read:

7 Don’t know/Not sure

9 Refused

Core Section 2: Healthy Days

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
CHD.01	Now thinking about your physical health, which includes physical illness and injury, for how many days during the past 30 days was your physical health not good?	PHYSHLTH	_ _ Number of days (01-30) 88 None 77 Don’t know/not sure 99 Refused		88 may be coded if respondent says “never” or “none” It is not necessary to ask respondents to provide a number if they indicate that this never occurs.
CHD.02	Now thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good?	MENTHLTH	_ _ Number of days (01-30) 88 None 77 Don’t know/not sure 99 Refused		88 may be coded if respondent says “never” or “none” It is not necessary to ask respondents to provide a number if they indicate that this never occurs.
				Skip CHD.03 if CHD.01, PHYSHLTH, is 88 and CHD.02, MENTHLTH, is 88
CHD.03	During the past 30 days, for about how many days did poor physical or mental health keep you from doing your usual activities, such as self-care, work, or recreation?	POORHLTH	_ _ Number of days (01-30) 88 None 77 Don’t know/not sure 99 Refused		88 may be coded if respondent says “never” or “none” It is not necessary to ask respondents to provide a number if they indicate that this never occurs.

Core Section 3: Health Care Access

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
CHCA.01	What is the current primary source of your health insurance?		Read if necessary: 01 A plan purchased through an employer or union (including plans purchased through another person's employer) 02 A private nongovernmental plan that you or another family member buys on your own 03 Medicare 04 Medigap 05 Medicaid 06 Children's Health Insurance Program (CHIP) 07 Military related health care: TRICARE (CHAMPUS) / VA health care / CHAMP- VA 08 Indian Health Service 09 State sponsored health plan 10 Other government program 88 No coverage of any type 77 Don’t Know/Not Sure 99 Refused		If respondent has multiple sources of insurance, ask for the one used most often. If respondents give the name of a health plan rather than the type of coverage ask whether this is insurance purchased independently, through their employer, or whether it is through Medicaid or CHIP.
CHCA.01
CHCA.02	Do you have one person or a group of doctors that you think of as your personal health care provider?		1 Yes, only one 2 More than one 3 No 7 Don’t know / Not sure 9 Refused		If no, read: Is there more than one, or is there no person who you think of as your personal doctor or health care provider? NOTE: if the respondent had multiple doctor groups then it would be more than one—but if they had more than one doctor in the same group it would be one.
CHCA.03	Was there a time in the past 12 months when you needed to see a doctor but could not because you could not afford it?		1 Yes 2 No 7 Don’t know / Not sure 9 Refused
CHCA.04	About how long has it been since you last visited a doctor for a routine checkup?	CHECKUP1	Read if necessary: 1 Within the past year (anytime less than 12 months ago) 2 Within the past 2 years (1 year but less than 2 years ago) 3 Within the past 5 years (2 years but less than 5 years ago) 4 5 or more years ago Do not read: 7 Don’t know / Not sure 8 Never 9 Refused		Read if necessary: A routine checkup is a general physical exam, not an exam for a specific injury, illness, or condition.

Core Section 4: Chronic Health Conditions

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
Prologue	Has a doctor, nurse, or other health professional ever told you that you had any of the following? For each, tell me Yes, No, Or You’re Not Sure.
CCHC.01	Ever told you that you had a heart attack also called a myocardial infarction?	CVDINFR4	1 Yes 2 No 7 Don’t know / Not sure 9 Refused
CCHC.02	(Ever told) (you had) angina or coronary heart disease?	CVDCRHD4	1 Yes 2 No 7 Don’t know / Not sure 9 Refused
CCHC.03	(Ever told) (you had) a stroke?	CVDSTRK3	1 Yes 2 No 7 Don’t know / Not sure 9 Refused
CCHC.04	(Ever told) (you had) asthma?	ASTHMA3	1 Yes
CCHC.04	(Ever told) (you had) asthma?	ASTHMA3	2 No 7 Don’t know / Not sure 9 Refused	Go to CCHC.06
CCHC.05	Do you still have asthma?	ASTHNOW	1 Yes 2 No 7 Don’t know / Not sure 9 Refused
CCHC.06	(Ever told) (you had) skin cancer that is not melanoma?	*NEW*	1 Yes 2 No 7 Don’t know / Not sure 9 Refused
CCHC.07	(Ever told) (you had) any melanoma or any other types of cancer?	*NEW*	1 Yes 2 No 7 Don’t know / Not sure 9 Refused
CCHC.08	(Ever told) (you had) C.O.P.D. (chronic obstructive pulmonary disease), emphysema or chronic bronchitis?	CHCCOPD3	1 Yes 2 No 7 Don’t know / Not sure 9 Refused
CCHC.09	(Ever told) (you had) a depressive disorder (including depression, major depression, dysthymia, or minor depression)?	ADDEPEV3	1 Yes 2 No 7 Don’t know / Not sure 9 Refused
CCHC.10	Not including kidney stones, bladder infection or incontinence, were you ever told you had kidney disease?	CHCKDNY2	1 Yes 2 No 7 Don’t know / Not sure 9 Refused		Read if necessary: Incontinence is not being able to control urine flow.
CCHC.11	(Ever told) (you had) some form of arthritis, rheumatoid arthritis, gout, lupus, or fibromyalgia?	HAVARTH4	1 Yes 2 No 7 Don’t know / Not sure 9 Refused		Do not read: Arthritis diagnoses include: rheumatism, polymyalgia rheumatic, osteoarthritis (not osteoporosis), tendonitis, bursitis, bunion, tennis elbow, carpal tunnel syndrome, tarsal tunnel syndrome, joint infection, Reiter’s syndrome, ankylosing spondylitis; spondylosis, rotator cuff syndrome, connective tissue disease, scleroderma, polymyositis, Raynaud’s syndrome, vasculitis, giant cell arteritis, Henoch-Schonlein purpura, Wegener’s granulomatosis, polyarteritis nodosa)
CCHC.12	(Ever told) (you had) diabetes?	DIABETE4	1 Yes		If yes and respondent is female, ask: was this only when you were pregnant? If respondent says pre-diabetes or borderline diabetes, use response code 4.
CCHC.12	(Ever told) (you had) diabetes?	DIABETE4	2 Yes, but female told only during pregnancy 3 No 4 No, pre-diabetes or borderline diabetes 7 Don’t know / Not sure 9 Refused	Go to Pre-Diabetes Optional Module (if used). Otherwise, go to next section.
CCHC.13	How old were you when you were told you had diabetes?	DIABAGE3	_ _ Code age in years [97 = 97 and older] 98 Don‘t know / Not sure 99 Refused	Go to Diabetes Module if used, otherwise go to next section.

Core Section 5: Demographics

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)			SKIP INFO/ CATI Note		Interviewer Note (s)		Column(s)
CDEM.01	What is your age?	AGE	_ _ Code age in years 07 Don’t know / Not sure 09 Refused
CDEM.02	Are you Hispanic, Latino/a, or Spanish origin?	HISPANC3	If yes, read: Are you… 1 Mexican, Mexican American, Chicano/a 2 Puerto Rican 3 Cuban 4 Another Hispanic, Latino/a, or Spanish origin Do not read: 5 No 7 Don’t know / Not sure 9 Refused					One or more categories may be selected.
CDEM.03	Which one or more of the following would you say is your race?	MRACE1	Please read: 10 White 20 Black or African American 30 American Indian or Alaska Native 40 Asian 41 Asian Indian 42 Chinese 43 Filipino 44 Japanese 45 Korean 46 Vietnamese 47 Other Asian 50 Pacific Islander 51 Native Hawaiian 52 Guamanian or Chamorro 53 Samoan 54 Other Pacific Islander Do not read: 60 Other 88 No additional choices 77 Don’t know / Not sure 99 Refused			.		If 40 (Asian) or 50 (Pacific Islander) is selected read and code subcategories underneath major heading. One or more categories may be selected.
						If more than one response to CDEM.03; continue. Otherwise, go to CDEM.05
CDEM.04	Which one of these groups would you say best represents your race?	ORACE3	Please read: 10 White 20 Black or African American 30 American Indian or Alaska Native 40 Asian 41 Asian Indian 42 Chinese 43 Filipino 44 Japanese 45 Korean 46 Vietnamese 47 Other Asian 50 Pacific Islander 51 Native Hawaiian 52 Guamanian or Chamorro 53 Samoan 54 Other Pacific Islander Do not read: 60 Other 77 Don’t know / Not sure 99 Refused					If 40 (Asian) or 50 (Pacific Islander) is selected read and code subcategories underneath major heading. If respondent has selected multiple races in previous and refuses to select a single race, code refused
						If using SOGI module, insert here. Sex at birth module may be inserted here if not used in the screening section.
Prologue	The next two questions are about sexual orientation and gender identity
					If sex= male (using BIRTHSEX, CELLSEX, LANDSEX ) continue, otherwise go to MSOGI.01b.
MSOGI.01a	Which of the following best represents how you think of yourself?	SOMALE		1 = Gay 2 = Straight, that is, not gay 3 = Bisexual 4 = Something else 7 = I don't know the answer 9 = Refused			Read if necessary: We ask this question in order to better understand the health and health care needs of people with different sexual orientations. Please say the number before the text response. Respondent can answer with either the number or the text/word.		551
					If sex= female (using BIRTHSEX, CELLSEX, LANDSEX ) continue, otherwise go to MSOGI.02.
MSOGI.01b	Which of the following best represents how you think of yourself?	SOFEMALE		1 = Lesbian or Gay 2 = Straight, that is, not gay 3 = Bisexual 4 = Something else 7 = I don't know the answer 9 = Refused	.		Read if necessary: We ask this question in order to better understand the health and health care needs of people with different sexual orientations. Please say the number before the text response. Respondent can answer with either the number or the text/word.		552
MSOGI.02	Do you consider yourself to be transgender?	TRNSGNDR		1 Yes, Transgender, male-to-female 2 Yes, Transgender, female to male 3 Yes, Transgender, gender nonconforming 4 No 7 Don’t know/not sure 9 Refused			Read if necessary: Some people describe themselves as transgender when they experience a different gender identity from their sex at birth. For example, a person born into a male body, but who feels female or lives as a woman would be transgender. Some transgender people change their physical appearance so that it matches their internal gender identity. Some transgender people take hormones and some have surgery. A transgender person may be of any sexual orientation – straight, gay, lesbian, or bisexual. If asked about definition of gender non-conforming: Some people think of themselves as gender non-conforming when they do not identify only as a man or only as a woman. If yes, ask Do you consider yourself to be 1. male-to-female, 2. female-to-male, or 3. gender non-conforming? Please say the number before the text response. Respondent can answer with either the number or the text/word.		553

CDEM.05	Are you…	MARITAL	Please read: 1 Married 2 Divorced 3 Widowed 4 Separated 5 Never married Or 6 A member of an unmarried couple Do not read: 9 Refused
CDEM.06	What is the highest grade or year of school you completed?	EDUCA	Read if necessary: 1 Never attended school or only attended kindergarten 2 Grades 1 through 8 (Elementary) 3 Grades 9 through 11 (Some high school) 4 Grade 12 or GED (High school graduate) 5 College 1 year to 3 years (Some college or technical school) 6 College 4 years or more (College graduate) Do not read: 9 Refused
CDEM.07	Do you own or rent your home?	RENTHOM1	1 Own 2 Rent 3 Other arrangement 7 Don’t know / Not sure 9 Refused					Other arrangement may include group home, staying with friends or family without paying rent. Home is defined as the place where you live most of the time/the majority of the year. Read if necessary: We ask this question in order to compare health indicators among people with different housing situations.
CDEM.08	In what county do you currently live?	CTYCODE2	_ _ _ANSI County Code 777 Don’t know / Not sure 999 Refused 888 County from another state
CDEM.09	What is the ZIP Code where you currently live?	ZIPCODE1	_ _ _ _ _ 77777 Do not know 99999 Refused
						If cell interview go to CDEM12
CDEM.13	Have you ever served on active duty in the United States Armed Forces, either in the regular military or in a National Guard or military reserve unit?	VETERAN3	1 Yes 2 No 7 Don’t know / Not sure 9 Refused					Read if necessary: Active duty does not include training for the Reserves or National Guard, but DOES include activation, for example, for the Persian Gulf War.
CDEM.14	Are you currently…?	EMPLOY1	Read: 1 Employed for wages 2 Self-employed 3 Out of work for 1 year or more 4 Out of work for less than 1 year 5 A Homemaker 6 A Student 7 Retired Or 8 Unable to work Do not read: 9 Refused					If more than one, say “select the category which best describes you”.
CDEM.15	How many children less than 18 years of age live in your household?	CHILDREN	_ _ Number of children 88 None 99 Refused
CDEM.16	Is your annual household income from all sources—	*NEW*	Read if necessary: 01 Less than $10,000? 02 Less than $15,000? ($10,000 to less than $15,000) 03 Less than $20,000? ($15,000 to less than $20,000) 04 Less than $25,000 05 Less than $35,000 If ($25,000 to less than $35,000) 06 Less than $50,000 If ($35,000 to less than $50,000) 07 Less than $75,000? ($50,000 to less than $75,000) 08 Less than $100,000? ($75,000 to less than $100,000) 09 Less than $150,000? ($100,000 to less than $150,000)? 10 Less than $200,000? ($150,000 to less than $200,000) 11 $200,000 or more Do not read: 77 Don’t know / Not sure 99 Refused			SEE CATI information of order of coding; Start with category 05 and move up or down categories.		If respondent refuses at ANY income level, code ‘99’ (Refused)
						Skip if Male (MSAB.01, BIRTHSEX, is coded 1). If MSAB.01=missing and (CP05=1 or LL12=1; or LL09 = 1 or LL07 =1). Or Age >49
CDEM.17	To your knowledge, are you now pregnant?	PREGNANT	1 Yes 2 No 7 Don’t know / Not sure 9 Refused
CDEM.18	About how much do you weigh without shoes?	WEIGHT2	_ _ _ _ Weight (pounds/kilograms) 7777 Don’t know / Not sure 9999 Refused					If respondent answers in metrics, put 9 in first column. Round fractions up
CDEM.19	About how tall are you without shoes?	HEIGHT3	_ _ / _ _ Height (ft / inches/meters/centimeters) 77/ 77 Don’t know / Not sure 99/ 99 Refused					If respondent answers in metrics, put 9 in first column. Round fractions down

Core Section 6: Disability

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
CDIS.01	Some people who are deaf or have serious difficulty hearing use assistive devices to communicate by phone. Are you deaf or do you have serious difficulty hearing?	DEAF	1 Yes 2 No 7 Don’t know / Not sure 9 Refused
CDIS.02	Are you blind or do you have serious difficulty seeing, even when wearing glasses?	BLIND	1 Yes 2 No 7 Don’t know / Not sure 9 Refused
CDIS.03	Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering, or making decisions?	DECIDE	1 Yes 2 No 7 Don’t know / Not sure 9 Refused
CDIS.04	Do you have serious difficulty walking or climbing stairs?	DIFFWALK	1 Yes 2 No 7 Don’t know / Not sure 9 Refused
CDIS.05	Do you have difficulty dressing or bathing?	DIFFDRES	1 Yes 2 No 7 Don’t know / Not sure 9 Refused
CDIS.06	Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone such as visiting a doctor’s office or shopping?	DIFFALON	1 Yes 2 No 7 Don’t know / Not sure 9 Refused

Core Section 7: Colorectal Cancer Screening

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
				If Section CDEM.01, AGE, is less than 45 go to next module.
CCRC.01	Colonoscopy and sigmoidoscopy are exams to check for colon cancer. Have you ever had either of these exams?	HADSIGM3	1 Yes	Go to CCRC.02
CCRC.01		HADSIGM3	2 No 7 Don’t know/ not sure 9 Refused	Go to CCRC.06
CCRC.02	Have you had a colonoscopy, a sigmoidoscopy, or both?		1 Colonoscopy	Go to CCRC.03
			2 Sigmoidoscopy	Go to CCRC.04
			3 Both 7 Don’t know/Not sure	Go to CCRC.05
			9 Refused	Go to CCRC.06
CCRC.03	How long has it been since your most recent colonoscopy?		1 Within the past year (anytime less than 12 months ago) 2 Within the past 2 years (1 year but less than 2 years ago) 3 Within the past 3 years (2 years but less than 3 years ago) 4 Within the past 5 years (3 years but less than 5 years ago) 5 5 or more years ago Do not read: 7 Don't know / Not sure 9 Refused	Go to CCRC.06
CCRC.04	How long has it been since your most recent sigmoidoscopy?		1 Within the past year (anytime less than 12 months ago) 2 Within the past 2 years (1 year but less than 2 years ago) 3 Within the past 3 years (2 years but less than 3 years ago) 4 Within the past 5 years (3 years but less than 5 years ago) 5 5 or more years ago Do not read: 7 Don't know / Not sure 9 Refused	Go to CCRC.06
CCRC.05	How long has it been since your most recent colonoscopy or sigmoidoscopy?	LASTSIG3	1 Within the past year (anytime less than 12 months ago) 2 Within the past 2 years (1 year but less than 2 years ago) 3 Within the past 3 years (2 years but less than 3 years ago) 4 Within the past 5 years (3 years but less than 5 years ago) 5 5 or more years ago Do not read: 7 Don't know / Not sure 9 Refused
CCRC.06	Have you ever had any other kind of test for colorectal cancer, such as virtual colonoscopy, CT colonography, blood stool test, FIT DNA, or Cologuard test?		1 Yes	Go to CCRC.07
CCRC.06			2 No 7 Don’t Know/Not sure 9 Refused	Go to Next Module
CCRC.07	A virtual colonoscopy uses a series of X-rays to take pictures of inside the colon. Have you ever had a virtual colonoscopy?		1 Yes	Go to CCRC.08	CT colonography, sometimes called virtual colonoscopy, is a new type of test that looks for cancer in the colon. Unlike regular colonoscopies, you do not need medication to make you sleepy during the test. In this new test, your colon is filled with air and you are moved through a donut-shaped X-ray machine as you lie on your back and then your stomach.
CCRC.07			2 No 7 Don’t Know/Not sure 9 Refused	Go to CCRC.09
CCRC.08	When was your most recent CT colonography or virtual colonoscopy?		Read if necessary: 1 Within the past year (anytime less than 12 months ago) 2 Within the past 2 years (1 year but less than 2 years ago) 3 Within the past 3 years (2 years but less than 3 years ago) 4 Within the past 5 years (3 years but less than 5 years ago) 5 5 or more years ago Do not read: 7 Don’t know / Not sure 9 Refused
CCRC.09	One stool test uses a special kit to obtain a small amount of stool at home and returns the kit to the doctor or the lab. Have you ever had this test?		1 Yes	Go to CCRC.10	The blood stool or occult blood test, fecal immunochemical or FIT test determine whether you have blood in your stool or bowel movement and can be done at home using a kit. You use a stick or brush to obtain a small amount of stool at home and send it back to the doctor or lab.
CCRC.09			2 No 7 Don’t know/ not sure 9 Refused	Go to CCRC.11
CCRC.10	How long has it been since you had this test?		Read if necessary: 1 Within the past year (anytime less than 12 months ago) 2 Within the past 2 years (1 year but less than 2 years ago) 3 Within the past 3 years (2 years but less than 3 years ago) 4 Within the past 5 years (3 years but less than 5 years ago) 5 5 or more years ago Do not read: 7 Don’t know / Not sure 9 Refused
CCRC.11	Another stool test uses a special kit to obtain an entire bowel movement at home and returns the kit to a lab. Have you ever had this Cologuard test?		1 Yes	Go to CCRC.12	Cologuard is a new type of stool test for colon cancer. Unlike other stool tests, Cologuard looks for changes in DNA in addition to checking for blood in your stool. The Cologuard test is shipped to your home in a box that includes a container for your stool sample.
CCRC.11			2 No 7 Don’t Know/Not sure 9 Refused	Go to Next Module
CCRC.12	Was the blood stool or FIT (you reported earlier) conducted as part of a Cologuard test?		1 Yes 2 No 7 Don’t Know/Not sure 9 Refused
CCRC.13	How long has it been since you had this test?		Read if necessary: 1 Within the past year (anytime less than 12 months ago) 2 Within the past 2 years (1 year but less than 2 years ago) 3 Within the past 3 years (2 years but less than 3 years ago) 4 Within the past 5 years (3 years but less than 5 years ago) 5 5 or more years ago Do not read: 7 Don’t know / Not sure 9 Refused

Core Section 8: Tobacco Use

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
CTOB.01	Have you smoked at least 100 cigarettes in your entire life?	SMOKE100	1 Yes		Do not include: electronic cigarettes (e-cigarettes, njoy, bluetip, JUUL), herbal cigarettes, cigars, cigarillos, little cigars, pipes, bidis, kreteks, water pipes (hookahs) or marijuana. 5 packs = 100 cigarettes.
CTOB.01		SMOKE100	2 No 7 Don’t know/Not Sure 9 Refused	Go to CTOB.03
CTOB.02	Do you now smoke cigarettes every day, some days, or not at all?	SMOKDAY2	1 Every day 2 Some days 3 Not at all 7 Don’t know / Not sure 9 Refused
CTOB.03	Do you currently use chewing tobacco, snuff, or snus every day, some days, or not at all?	USENOW3	1 Every day 2 Some days 3 Not at all 7 Don’t know / Not sure 9 Refused		Read if necessary: Snus (Swedish for snuff) is a moist smokeless tobacco, usually sold in small pouches that are placed under the lip against the gum.
CTOB.04	Do you now use e-cigarettes or other electronic vaping products every day, some days or not at all?		1 Every day 2 Some days 3 Not at all 4 Never used e-cigs 7 Don’t know / Not sure 9 Refused		Electronic cigarettes (e-cigarettes) and other electronic vaping products include electronic hookahs (e-hookahs), vape pens, e-cigars, and others. These products are battery-powered and usually contain nicotine and flavors such as fruit, mint, or candy. Brands you may have heard of are JUUL, NJOY, or blu. Interviewer note: These questions concern electronic vaping products for nicotine use. The use of electronic vaping products for marijuana use is not included in these questions.

Core Section 9: Lung Cancer Screening

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
				If CTOB.01=1 (yes) and CTOB.02 = 1, 2, or 3 (every day, some days, or not at all) continue, else go to LCSCTSCN.
CLC.01	You’ve told us that you have smoked in the past or are currently smoking. The next questions are about screening for lung cancer. How old were you when you first started to smoke cigarettes regularly?	LCSFIRST	_ _ _ Age in Years (001 – 100) 777 Don't know/Not sure 999 Refused		Regularly is at least one cigarette or more on days that a respondent smokes (either every day or some days) or smoked (not at all). If respondent indicates age inconsistent with previously entered age, verify that this is the correct answer and change the age of the respondent regularly smoking or make a note to correct the age of the respondent.
CLC.01		LCSFIRST	888 Never smoked cigarettes regularly	Go to LCSCTSCN
CLC.02	How old were you when you last smoked cigarettes regularly?	LCSLAST	_ _ _ Age in Years (001 – 100) 777 Don't know/Not sure 999 Refused
CLC.03	On average, when you [smoke/ smoked] regularly, about how many cigarettes {do/did} you usually smoke each day?	LCSNUMCG	_ _ _ Number of cigarettes 777 Don't know/Not sure 999 Refused		Regularly is at least one cigarette or more on days that a respondent smokes (either every day or some days) or smoked (not at all). Respondents may answer in packs instead of number of cigarettes. Below is a conversion table: 0.5 pack = 10 cigarettes/ 1.75 pack = 35 cigarettes/ 0.75 pack = 15 cigarettes/ 2 packs = 40 cigarettes/ 1 pack = 20 cigarettes/ 2.5 packs= 50 cigarettes/ 1.25 pack = 25 cigarettes/ 3 packs= 60 cigarettes/ 1.5 pack = 30 cigarettes
CLC.04	The next question is about CT or CAT scans of your chest area. During this test, you lie flat on your back and are moved through an open, donut shaped x-ray machine. In the last 12 months, did you have a CT or CAT scan?		1 Yes 2 No 7 Don't know/not sure 9 Refused
CLC.04	Were any of the CT or CAT scans of your chest area done mainly to check or screen for lung cancer?		1 Yes 2 No 7 Don't know/not sure 9 Refused
CLC.05	When did you have your most recent CT or CAT scan of your chest area mainly to check or screen for lung cancer?		Read only if necessary: 1 Within the past year (anytime less than 12 months ago) 2 Within the past 2 years (1 year but less than 2 years) 3 Within the past 3 years (2 years but less than 3 years) 4 Within the past 5 years (3 years but less than 5 years) 5 Within the past 10 years (5 years but less than 10 years ago) 6 or more years ago Do not read: 7 Don’t know / Not sure 9 Refused

Core Section 10: Alcohol Consumption

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
CALC.01	During the past 30 days, how many days per week or per month did you have at least one drink of any alcoholic beverage such as beer, wine, a malt beverage or liquor?	ALCDAY5	1 _ _ Days per week 2 _ _ Days in past 30 days		Read if necessary: A 40-ounce beer would count as 3 drinks, or a cocktail drink with 2 shots would count as 2 drinks.
CALC.01		ALCDAY5	888 No drinks in past 30 days 777 Don’t know / Not sure 999 Refused	Go to next section
CALC.02	One drink is equivalent to a 12-ounce beer, a 5-ounce glass of wine, or a drink with one shot of liquor. During the past 30 days, on the days when you drank, about how many drinks did you drink on the average?	AVEDRNK3	_ _ Number of drinks 88 None 77 Don’t know / Not sure 99 Refused		Read if necessary: A 40-ounce beer would count as 3 drinks, or a cocktail drink with 2 shots would count as 2 drinks.
CALC.03	Considering all types of alcoholic beverages, how many times during the past 30 days did you have X [CATI X = 5 for men, X = 4 for women] or more drinks on an occasion?	DRNK3GE5	_ _ Number of times 77 Don’t know / Not sure 88 no days 99 Refused	CATI X = 5 for men, X = 4 for women (states may use sex at birth to determine sex if module is adopted)
CALC.04	During the past 30 days, what is the largest number of drinks you had on any occasion?	MAXDRNKS	_ _ Number of drinks 77 Don’t know / Not sure 99 Refused
CALC.05	When answering the questions about the number of drinks you had on an occasion, which of the following best describes how you thought of an “occasion”? Was it a few hours, such as an evening or going out for the night, one day, one weekend, a special event or celebration such as a birthday, wedding, or sporting event?		1 A few hours, such as an evening or going out for the night, 2 one day, 3 One weekend, 4 A special event or celebration such as a birthday, wedding, or sporting event 5 Other 7 Don’t know/ Not sure 9 Refused
CALC.06	Earlier I described a standard drink size as equivalent to a 12-ounce beer, a 5-ounce glass of wine, or a drink with one shot of liquor. In thinking about the size of your drinks, how do they compare to the standard drink size? Are the drinks you described generally larger than the standard drink size, generally smaller than the standard drink size or about the same size as a standard drink.		1 Generally larger than the standard drink size, 2 Generally smaller than the standard drink size or
			3 about the same size as a standard drink 7 Don’t know/ Not sure 9 Refused	Go to next section
				Go to next section
CALC.07	When answering questions about the number of drinks you had, did you base your answer on the size of your drinks or the size of a standard drink?		1 the size of your drinks 2 the size of a standard drink 7 Don’t know/ Not sure 9 Refused

Emerging Core: Long-term COVID Effects

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
COVID.01	Has a doctor, nurse, or other health professional ever told you that you tested positive for COVID 19?	*NEW*	1 Yes		Positive tests include antibody or blood testing as well as other forms of testing for COVID, such a nasal swabbing or throat swabbing. Do not include instances where a healthcare professional told you that you likely had the virus without a test to confirm.
COVID.01		*NEW*	2 No 7 Don’t know / Not sure 9 Refused	Go to next section
COVID.02	Did you have any symptoms lasting 3 months or longer that you did not have prior to having coronavirus or COVID-19?	*NEW*	1 Yes		Long term conditions may be an indirect effect of COVID 19. These long term conditions may not be related to the virus itself
COVID.02		*NEW*	2 No 7 Don’t know / Not sure 9 Refused	Go to next section
COVID.03	Which of the following was the primary symptom that you experienced? Was it….	*NEW*	READ 1 Tiredness or fatigue 2 Difficulty thinking or concentrating or forgetfulness/memory problems (sometimes referred to as “brain fog”) 3 Difficulty breathing or shortness of breath 4 Joint or muscle pain 5 Fast-beating or pounding heart (also known as heart palpitations) or chest pain 6 Dizziness on standing 7 Depression, anxiety, or mood changes 8 Symptoms that get worse after physical or mental activities 9 You did not have any long-term symptoms that limited your activities.77 Don’t know/Not sure 99 Refused

Module 1: COVID Vaccination

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)

MCOV.01	Have you had a COVID-19 vaccination?	COVIDVAC	1 Yes	Go to MCOV.03 (COVIDNUM)
			2 No	Go to MCOV.02 (COVACGET)
			7 Don’t know / Not sure 9 Refused	Go to next section
MCOV.02	Would you say you will definitely get a vaccine, will probably get a vaccine, will probably not get a vaccine, will definitely not get a vaccine, or are you not sure?	COVACGET	1 = Will definitely get a vaccine 2 = Will probably get a vaccine 3 = Will probably not get a vaccine 4 = Will definitely not get a vaccine 7 = Don’t know/Not sure 9 = Refused	Go to next section
MCOV.03	How many COVID-19 vaccinations have you received?	COVIDNUM	1 One
			2 Two or more	Go to MCOV.05
			7 Don’t know / Not sure 9 Refused	Go to next module
				Skip MCOV4 (COVINT) if COVIDNUM = 2.
MCOV.04	Which of the following best describes your intent to take the recommended COVID vaccinations… Would you say you have already received all recommended doses, plan to receive all recommended doses or do not plan to receive all recommended doses?	COVIDINT	1 = Already received all recommended doses 2 = Plan to receive all recommended doses 3 = Do not plan to receive all recommended doses 7 = Don’t know/Not sure 9 = Refused
MCOV.05	During what month and year did you receive your (first) COVID-19 vaccination?	COVIDFST	_ _ / _ _ _ _ Month / Year 77 / 7777 Don’t know / Not sure 09 / 9999 Refused	If respondent indicated only one vaccine do not read word “first”
MCOV.06	During what month and year did you receive your second COVID-19 vaccination?	COVIDFST	_ _ / _ _ _ _ Month / Year 77 / 7777 Don’t know / Not sure 09 / 9999 Refused

Module 2: Prediabetes

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
				Skip if CCHC.12, DIABETE4, is coded 1. To be asked following Core CCHC.12;
M01.01	Have you had a test for high blood sugar or diabetes within the past three years?	PDIABTST	1 Yes 2 No 7 Don’t know/ not sure 9 Refused
				Skip if CCHC.12, DIABETE4, is coded 1; If CCHC.11, DIABETE4, is coded 4 automatically code M01.02, PREDIAB1, equal to 1 (yes)
M01.02	Have you ever been told by a doctor or other health professional that you have pre-diabetes or borderline diabetes?	PREDIAB1	1 Yes 2 Yes, during pregnancy 3 No 7 Don’t know / Not sure 9 Refused		If Yes and respondent is female, ask: Was this only when you were pregnant?

Module 3: Diabetes

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
				Skip if CCHC.12 is not equal to 1.
M02.01	According to your doctor or other health professional, what type of diabetes do you have?	*NEW*	1 Type 1 2 Type 2 7 Don’t know/ Not sure 9 Refused
M02.02	Are you now taking insulin?	INSULIN	1 Yes 2 No 7 Don’t know/ not sure 9 Refused
M02.03	About how often do you check your blood for glucose or sugar?	BLDSUGAR	1 _ _ Times per day 2 _ _ Times per week 3 _ _ Times per month 4 _ _ Times per year 888 Never 777 Don’t know / Not sure 999 Refused		Read if necessary: Include times when checked by a family member or friend, but do not include times when checked by a health professional. Do not read: If the respondent uses a continuous glucose monitoring system (a sensor inserted under the skin to check glucose levels continuously), fill in ‘98 times per day.’
M02.04	Including times when checked by a family member or friend, about how often do you check your feet for any sores or irritations?	FEETCHK3	1 _ _ Times per day 2 _ _ Times per week 3 _ _ Times per month 4 _ _ Times per year 555 No feet 888 Never 777 Don’t know / Not sure 999 Refused
M02.05	About how many times in the past 12 months have you seen a doctor, nurse, or other health professional for your diabetes?	DOCTDIAB	_ _ Number of times [76 = 76 or more] 88 None 77 Don’t know / Not sure 99 Refused
M02.06	About how many times in the past 12 months has a doctor, nurse, or other health professional checked you for A-one-C?	CHKHEMO3	_ _ Number of times [76 = 76 or more] 88 None 98 Never heard of A-one-C test 77 Don’t know / Not sure 99 Refused		Read if necessary: A test for A-one-C measures the average level of blood sugar over the past three months.
M02.07	About how many times in the past 12 months has a health professional checked your feet for any sores or irritations?	FEETCHK	_ _ Number of times [76 = 76 or more] 88 None 77 Don’t know / Not sure 99 Refused	If M02.03 = 555 (No feet), go to M02.07
M02.08	When was the last time you had an eye exam in which the pupils were dilated, making you temporarily sensitive to bright light?	EYEEXAM1	Read if necessary: 1 Within the past month (anytime less than 1 month ago) 2 Within the past year (1 month but less than 12 months ago) 3 Within the past 2 years (1 year but less than 2 years ago) 4 2 or more years ago Do not read: 7 Don’t know / Not sure 8 Never 9 Refused
M02.09	When was the last time a doctor, nurse or other health professional took a photo of the back of your eye with a specialized camera?	*NEW*	Read if necessary: 1 Within the past month (anytime less than 1 month ago) 2 Within the past year (1 month but less than 12 months ago) 3 Within the past 2 years (1 year but less than 2 years ago) 4 2 or more years ago Do not read: 7 Don’t know / Not sure 8 Never 9 Refused
M02.10	Has a doctor ever told you that diabetes has affected your eyes or that you had retinopathy?	DIABEYE	1 Yes 2 No 7 Don’t know/ not sure 9 Refused
M02.11	Have you ever taken a course or class in how to manage your diabetes yourself?	DIABEDU	1 Yes 2 No 7 Don’t know/ not sure 9 Refused

Module 4: Respiratory Health

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
M7.01	During the past 3 months, did you have a cough on most days?	COPDCOGH	1 Yes 2 No 7 Don’t know/ not sure 9 Refused
M7.02	During the past 3 months, did you cough up phlegm [FLEM] or mucus on most days?	COPDFLEM	1 Yes 2 No 7 Don’t know/ not sure 9 Refused
M7.03	Do you have shortness of breath either when hurrying on level ground or when walking up a slight hill or stairs?	COPDBRTH	1 Yes 2 No 7 Don’t know/ not sure 9 Refused
M7.04	Have you ever been given a breathing test to diagnose breathing problems?	COPDBTST	1 Yes 2 No 7 Don’t know/ not sure 9 Refused
M7.05	Over your lifetime, how many years have you smoked tobacco products?	COPDSMOK	_ _ Number of years (01-76) 88 Never smoked or smoked less than one year 77 Don’t know/Not sure 99 Refused

Module 5: Cancer Survivorship: Type of Cancer

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
				If CCHC.06 or CCHC.07 = 1 (Yes) continue, else go to next module.
MTOC.01	You’ve told us that you have had cancer. I would like to ask you a few more questions about your cancer. How many different types of cancer have you had?	CNCRDIFF	1 Only one 2 Two 3 Three or more
MTOC.01		CNCRDIFF	7 Don’t know / Not sure 9 Refused	Go to next module
MTOC.02	At what age were you told that you had cancer?	CNCRAGE	_ _ Age in Years (97 = 97 and older) 98 Don't know/Not sure 99 Refused		If MTOC.01= 2 (Two) or 3 (Three or more), ask: At what age were you first diagnosed with cancer? Read if necessary: This question refers to the first time they were told about their first cancer.
				If CCHC.06 = 1 (Yes) and MTOC.01 = 1 (Only one): ask Was it Melanoma or other skin cancer? then code MTOC.03 as a response of 21 if Melanoma or 22 if other skin cancer
MTOC.03	What kind of cancer is it?	*NEW*	Read if respondent needs prompting for cancer type: 01 Bladder 02 Blood 03 Bone 04 Brain 05 Breast 06 Cervix/Cervical 07 Colon 08 Esophagus/Esophageal 09 Gallbladder 10 Kidney 11 Larynx-trachea 12 Leukemia 13 Liver 14 Lung 15 Lymphoma 16 Melanoma 17 Mouth/tongue/lip 18 Ovary/Ovarian 19 Pancreas/Pancreatic 20 Prostate 21 Rectum/Rectal 22 Skin (non-melanoma) 23 Skin (don't know what kind) 24 Soft tissue (muscle or fat) 25 Stomach 26 Testis/Testicular 27 Throat - pharynx 28 Thyroid 29 Uterus/Uterine 30 Other Do not read: 77 Don’t know / Not sure 99 Refused		If MTOC.01 = 2 (Two) or 3 (Three or more), ask: With your most recent diagnoses of cancer, what type of cancer was it?

Module 6: Prostate Cancer Screening

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
				If respondent is ≤39 years of age or is female, go to next module.
MPCS.01	Have you ever had a P.S.A. test?	PSATEST1	1 Yes		A P.S.A. test is a blood test to detect prostate cancer. It is also called a prostate-specific antigen test.
MPCS.01	Have you ever had a P.S.A. test?	PSATEST1	2 No 7 Don’t know / Not sure 9 Refused	Go to M11.04
MPCS.02	Who first suggested this PSA test: you, your doctor, or someone else?		1 Self 2 Doctor, nurse, health care professional 3 Someone else 7 Don’t Know / Not sure 9 Refused
MPCS.03	About how long has it been since your most recent P.S.A. test?		Read if necessary: 1 Within the past year (anytime less than 12 months ago) 2 Within the past 2 years (1 year but less than 2 years ago) 3 Within the past 3 years (2 years but less than 3 years ago) 4 Within the past 5 years (3 years but less than 5 years ago) 5 5 or more years ago Do not read: 7 Don’t know / Not sure 9 Refused		A P.S.A. test is a blood test to detect prostate cancer. It is also called a prostate-specific antigen test.
MPCS.04	What was the main reason you had this P.S.A. test – was it …?	*NEW*	Read: 1 Part of a routine exam 2 Because of a problem 3 other reason Do not read: 7 Don’t know / Not sure 9 Refused		A P.S.A. test is a blood test to detect prostate cancer. It is also called a prostate-specific antigen test.
MPCS.05	When you met with a doctor, nurse, or other health professional, did they talk about the advantages, the disadvantages, or both advantages and disadvantages of the prostate-specific antigen or PSA test?	*NEW*	1 Advantages 2 Disadvantages 3 Both Advantages and disadvantages DO NOT READ 4. Neither 7 Don’t know/ not sure 9 Refused		A P.S.A. test is a blood test to detect prostate cancer. It is also called a prostate-specific antigen test.

Module 7: Marijuana Use

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
MMU.01	During the past 30 days, on how many days did you use marijuana or cannabis?	MARIJAN1	_ _ 01-30 Number of days		These questions are about marijuana or cannabis. Do not include hemp-based or CBD-only products in your responses.
MMU.01		MARIJAN1	88 None 77 Don’t know/not sure 99 Refused	Go to next module
MMU.02	During the past 30 days, did you smoke it (for example, in a joint, bong, pipe, or blunt)	*NEW*	1 Yes 2 No 7 Don’t Know/Not Sure 9 Refused
MMU.03	During the past 30 days, did you eat it (for example, in brownies, cakes, cookies, or candy)	*NEW*	1 Yes 2 No 7 Don’t Know/Not Sure 9 Refused
MMU.04	During the past 30 days, did you drink it (for example, in tea, cola, or alcohol)	*NEW*	1 Yes 2 No 7 Don’t Know/Not Sure 9 Refused
MMU.05	During the past 30 days, did you vaporize it (for example, in an e-cigarette-like vaporizer or another vaporizing device)	*NEW*	1 Yes 2 No 7 Don’t Know/Not Sure 9 Refused
MMU.06	During the past 30 days, did you dab it (for example, using a dabbing rig, knife, or dab pen)?	*NEW*	1 Yes 2 No 7 Don’t Know/Not Sure 9 Refused
MMU.07	During the past 30 days, did you use it in some other way?	*NEW*	1 Yes 2 No 7 Don’t Know/Not Sure 9 Refused

Module 8: Other Tobacco Use

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
MOTU.01	Currently, when you smoke cigarettes, do you usually smoke menthol cigarettes?	*NEW*	1 Yes 2 No 7 Don’t know / Not sure 9 Refused
MOTU.02	Currently, when you use e-cigarettes, do you usually use menthol e-cigarettes?	*NEW*	1 Yes 2 No 7 Don’t know / Not sure 9 Refused
MOTU.03	Prologue: The next questions are about heated tobacco products. Some people refer to these as “heat not burn” tobacco products. These heat tobacco sticks or capsules to produce a vapor. Some brands of heated tobacco products include iQOS [eye-kos], Glo, and Eclipse.	*NEW*
MOTU.04	Do you now use heated tobacco products every day, some days or not at all?	*NEW*	1 Every day 2 Some days	Go to next module
MOTU.04		*NEW*	3 Not at all 7 Don’t know / Not sure 9 Refused
MOTU.05	Before today, have you heard of heated tobacco products?	*NEW*	1 Yes 2 No 7 Don’t know / Not sure 9 Refused

Module 9: Family Planning

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
				Skip if sex= male or age> 49
MFP.01	In the past 12 months, did you have sex where a penis is inserted into the vagina, sometimes called penile‐vaginal sex?		1 Yes 2 No [GO TO NEXT MODULE]
MFP.02	The last time you had sex, what did you or your partner do to keep you from getting pregnant?		Read if necessary: 01 Female sterilization (Tubal ligation, Essure, or Adiana) 02 Male sterilization (vasectomy) 03 Contraceptive implant 04 Intrauterine device or IUD (Mirena, Levonorgestrel, ParaGard) 05 Shots (Depo-Provera) 06 Birth control pills, Contraceptive Ring (NuvaRing), Contraceptive patch (Ortho Evra) 07 Condoms (male or female) 08 Diaphragm, cervical cap, sponge, foam, jelly, film, or cream 09 Had sex at a time when less likely to get pregnant (rhythm or natural family planning) 10 Withdrawal or pulling out 11 Emergency contraception or the morning after pill (Plan B or ella) 12 Other method
MFP.03	The last time you had sex, what else, if anything, did you or your partner do to keep you from getting pregnant?		00 Nothing else 01 Female sterilization (Tubal ligation, Essure, or Adiana) 02 Male sterilization (vasectomy) 03 Contraceptive implant 04 Intrauterine device or IUD (Mirena, Levonorgestrel, ParaGard) 05 Birth control pills, Contraceptive Ring (NuvaRing), Contraceptive patch (Ortho Evra) 06 Shots (Depo-Provera), 07 Condoms (male or female) 08 Diaphragm, cervical cap, sponge, foam, jelly, film, or cream 09 Had sex at a time when less likely to get pregnant (rhythm or natural family planning) 10 Withdrawal or pulling out 11 Emergency contraception or the morning after pill (Plan B or Ella) 12 Other method
MFP.04	Where did you get the [contractive response from Q3] you used when you last had sex?		01 Private doctor’s office [GO TO Q7] 02 Community health clinic, Community clinic, Public health clinic [GO TO Q7] 03 Family planning or Planned Parenthood Clinic [GO TO Q7] 04 School or school-based clinic [GO TO Q7] 05 Hospital outpatient clinic, emergency room, regular hospital room [GO TO Q7] 06 Urgent care center, urgi-care or walk-in facility [GO TO Q7] 07 In- store health clinic (like CVS, Target, or Walmart) [GO TO Q7] 08 Health care visit with a pharmacist [GO TO Q7] 09 Website or app [GO TO Q7] 10 Some other place [GO TO Q7]
MFP.05	What was your main reason for not doing anything to prevent pregnancy the last time you had sex?		01 You didn’t think you were going to have sex/no regular partner 02 You just didn’t think about it 03 You wanted a pregnancy 04 You didn’t care if you got pregnant 05 You or your partner didn’t want to use birth control (side effects, don’t like birth control) 06 You had trouble getting or paying for birth control 07 You didn’t trust giving out your personal information to medical personnel 08 Didn’t think you or your partner could get pregnant (infertile or too old) 09 You were using withdrawal or “pulling out” 10 You had your tubes tied (sterilization) 11 Your partner had a vasectomy (sterilization) 12 You were breast-feeding or you just had a baby 13 You were assigned male at birth 14 Other reasons
MFP.06	If you could use any birth control method you wanted, what method would you use?		01 Female sterilization (Tubal ligation, Essure, or Adiana) [GO TO NEXT MODULE] 02 Male sterilization (vasectomy) [GO TO NEXT MODULE] 03 Contraceptive implant [GO TO NEXT MODULE] 04 Intrauterine device or IUD (Mirena, Levonorgestrel, ParaGard) [GO TO NEXT MODULE] 05 Shots (Depo-Provera) [GO TO NEXT MODULE] 06 Birth control pills, Contraceptive Ring (NuvaRing), Contraceptive patch (Ortho Evra) [GO TO NEXT MODULE] 07 Condoms (male or female) [GO TO NEXT MODULE] 08 Diaphragm, cervical cap, sponge, foam, jelly, film, or cream [GO TO NEXT MODULE] 09 Having sex at a time when less likely to get pregnant (rhythm or natural family planning) [GO TO NEXT MODULE] 10 Withdrawal or pulling out [GO TO NEXT MODULE] 11 Emergency contraception or the morning after pill (Plan B or ella) [GO TO NEXT MODULE] 12 Other method [GO TO NEXT MODULE] 13 I am using the method that I want to use [GO TO NEXT MODULE] 14 I don’t want to use any method [GO TO NEXT MODULE]

Closing Statement

Read

That was my last question. Everyone’s answers will be combined to help us provide information about the health practices of people in this state. Thank you very much for your time and cooperation.

8 October 2021

File Type	application/vnd.openxmlformats-officedocument.wordprocessingml.document
Author	Pierannunzi, Carol (CDC/ONDIEH/NCCDPHP)
File Modified	0000-00-00
File Created	2021-10-08